Millions of people are in desperate need of lifesaving humanitarian aid.

Some 4.8 million people have fled the country and an estimated 6.5 million have been internally displaced as government troops, opposition forces and insurgent groups battle for power and control of territory.

Spotlight: RAQQA

Hear from three MSF UK medics who helped set up a trauma stabilisation unit in Raqqa, after the city was taken from the so-called Islamic State group in October 2017.

In this episode of our Everyday Emergency podcast, doctors Javid Abdelmoneim and Pippa Pett, along with nurse Michael Shek, discuss saving lives in the rubble of a city littered with explosive devices.

The complex war has been characterised by extreme violence: civilian areas have been routinely bombed – often in ‘double-tap‘ attacks in which the initial strike is followed by a second on rescue teams or on the healthcare facility receiving the wounded; and there have been attacks resulting in symptoms of exposure to chemical agents.

In east Aleppo, since the siege began in July 2016, functioning hospitals have been damaged in over 35 separate attacks. Some hospitals have been hit multiple times and have been forced to close as a result.

The Syrian government continues to deny repeated requests by Médecins Sans Frontières/Doctors Without Borders (MSF) to access government-controlled areas. In a country where we should be running some of our largest medical programmes, the opportunities to reach people and to respond in a timely manner to the enormous needs remains extremely limited.

This is a forceful reminder of how access to medical care is by and large not respected and is in many cases directly targeted by those involved in the conflict and used for political purposes.

Following the Islamic State (IS) group’s abduction and release of MSF staff in 2014, and the impossibility of obtaining the necessary guarantees from IS leadership that MSF patients and staff will not be taken or harmed, the difficult decision was taken to withdraw from IS-controlled areas.

MSF’s activities have consequently been limited to regions controlled by opposition forces, or restricted to cross‐frontline and cross‐border support to medical networks.

MSF’s work in Syria: 2016

In 2016, we continued to operate directly in six medical facilities in regions controlled by opposition forces across northern Syria.

We are providing distance support to Syrian medical networks in areas where we cannot be directly present.

Aleppo governorate

Since 2014, we have been providing regular medical supplies to eight hospitals, six health centres and three first-aid points in eastern Aleppo city. However, following the consolidation of the siege by the government-led coalition in July 2016, these activities halted.

Although no longer able to offer direct support, we kept in close contact with the doctors and nurses we had been working with in eastern Aleppo. They testified to the immense suffering of the people trapped in the city, where civilian areas, including hospitals, were routinely hit in targeted or indiscriminate bombings and shellings.

In December, the Syrian government took full control of Aleppo city and thousands of people from the eastern part were evacuated to rural areas of Idlib and Aleppo governorates. Since then, we have been running mobile clinics and distributing relief items in these areas, where we also organised a vaccination campaign.

In Azaz district, north of Aleppo, we run the 34-bed Al Salamah hospital, offering a wide range of services including outpatient and inpatient consultations, emergency treatment, surgery and maternal care.

Patients needing further treatment are referred to other facilities in the district, or in Turkey. In 2016, our staff conducted 85,737 outpatient consultations, performed 1,598 surgical interventions and admitted 3,692 patients.

Renewed fighting in Azaz caused the displacement of more than 35,000 people: by April, more than 100,000 people were trapped between the frontline and the Turkish border.

We delivered relief items and hygiene kits for 4,345 families (26,070 people) and tents for 1,330 families. A water and sanitation programme was also implemented in one of the informal settlements east of Azaz town.

In the Kobanê/Ain al-Arab area of northern Syria, we have worked alongside the local health administration since March 2015 to re-establish basic health facilities and vaccination services, provide outpatient healthcare and implement psychological support programmes. We currently support nine primary health units, a maternity clinic and two hospitals.

More than 101,680 outpatient consultations and 138 surgical interventions were carried out in MSF-supported facilities. In rural Jarablus, we partnered with the Turkish NGO AID to assist three primary health centres.

In the summer, shifting frontlines and a military offensive caused civilians to flee Manbij and settle near the Euphrates river. We scaled up our support to help meet the needs of the displaced and host communities.

When people returned to their homes in August, they found that the city had been extensively planted with mines, booby traps and other explosive devices.

Over the course of just four weeks, an MSF-supported hospital in Kobanê treated more than 190 people injured by explosive devices in Manbij.

Idlib governorate

We continued to run a 20-bed burns hospital in Atmeh, providing patients with surgery, skin grafts, dressings and physiotherapy, as well as mental health support, emergency care and outpatient consultations.

We also run immunisation programmes, health education and disease surveillance activities in 180 camps and villages hosting approximately 165,000 internally displaced people around Atmeh, and ensure follow-up for patients requiring more specialised treatment in Turkey.

During 2016, our team in Atmeh hospital carried out 2,883 emergency consultations, and performed 3,696 surgical interventions. Four-hundred-and-thirty-nine patients were admitted to the inpatient wards and 398 were transferred to Turkey for further treatment. In the camps and villages, our staff administered more than 118,000 doses of vaccines to children under five.

In Qunaya, we scaled up our distance support to the regional referral hospital, comprehensively supporting all its services in terms of material and technical oversight. In 2016, the hospital provided: 105,168 outpatient consultations and 12,011 cases were treated in the inpatient department.

Teams also started supporting immunisation activities in Qunaya and Darkoush hospitals, administering a total of 53,341 vaccines.

Hassakeh governorate

Since 2013, our teams have been offering primary health services, with a particular focus on mother and child care and chronic diseases, through three health centres, including a maternity clinic.

These services are open to both internally displaced people and host communities, as well as to Iraqi refugees. This year, our teams provided:

44,873 general consultations, 8,257 of which were for children under five,

treatment for 951 patients with chronic diseases,

5,598 reproductive health consultations,

assistance for an average of 170 births each month.

Distance support to medical facilities across Syria

Since 2011, we have been supporting a growing number of medical facilities in some of the areas worst affected by conflict where we have no direct access.

This programme is mostly run from neighbouring countries and consists of donations of medicine, medical material and relief items; distance training for staff inside Syria; technical medical advice; and financial support to cover the facilities’ running costs.

In besieged areas, the medics’ reliance on our underground support is all the more critical as medical essentials are often removed from the official aid convoys by the besieging forces.

In 2016, regular support was given to 80 medical structures across Syria, including in Aleppo, Dara’a, Hama, Homs, Idlib, Quneitra and rural Damascus governorates. These facilities conducted:

more than 2.2 million outpatient consultations,

770,000 emergency room consultations,

225,000 surgeries,

and assisted over 29,000 births.

Not all of these activities can be solely attributed to our programmes: while some facilities are exclusively supported by us, many benefit from additional sources of assistance. Ad hoc support, such as medical donations, was provided to an additional 80 medical facilities across the country.